Organizing medical records for readability
September 26, 2012 5:41 PM   Subscribe

How can I organize my medical records and lab tests so that they are as easy as possible for a doctor or nurse to navigate?

I got a rare opportunity to have my medical case reviewed by a team of experts at a hospital. They have requested me to send my medical records and lab tests for them to review. The thing is that I have a ton of records and labs done over the years at different clinics, each with its own format/organization. It seems like it would be a challenge for a clinician to navigate these records and build a clear mental picture. I am motivated to make it as easy as possible for them to grok my records, since they only have limited time to review my case, and I don't want them to get frustrated or miss a relevant result that is buried among the noise. Also, by putting an effort into organizing these records, I want the clinic to see how much this matters to me.

Doctors/nurses: what are some things that make it easier for you to review medical records?

Here are some ideas I have:
- Highlighting the date on each record
- Highlighting abnormal results (e.g. lab results outside of the reference range)
- Writing a little comment on each record or lab result giving context (e.g. "this lab result was from before I started Treatment X")
- Ordering records chronologically or by specialty
- Making an index of my lab tests, so they can easily find all instances of a particular test over the years

(I called the office to ask them directly how they wanted the records organized, but the only person I could speak to was an admin who is not involved in reviewing clinical records.)
posted by wireless to Health & Fitness (10 answers total) 3 users marked this as a favorite
I wouldn't write directly on the records. What I would do is put an index/summary page first - what each record is, the date, and the result. In front of each new record, a single piece of paper with large type and a very very brief description of what they're about to look at. That is just what I would do.
posted by bleep at 5:46 PM on September 26, 2012 [1 favorite]

Don't worry about that. I've had a couple of diagnoses that took a lot of people in a lot of places to come to, and they know how to deal with the records. They do it all the time. Just make sure every piece of information gets to them, and write a narrative for yourself, so you can verbally tell them what happened and be there to answer questions.
posted by xingcat at 5:52 PM on September 26, 2012

When I review medical records I like to have all the physician notes in the front, in chronological order starting from most recent to furthest remote.

In terms of the testing, I would separate out radiology studies from blood work from urine tests and if you have a lot, maybe put them in a binder and have tabs so you can easily flip to the right section. Put all the same tests together, like if you have complete blood counts done, put them all together, again, in chronological order with the most recent first.

Then in the front of the record, you can put a summary "problem list" and put a date by each of the diagnoses you've received. The summary problem list could take this format:
1. Medical History
2. Surgical History
3. Family History
4. Allergies
5. Medications (current) including doses

If you have one good history and physical done recently by a doctor who knows you well and you think it is comprehensive, you might not need to do that because it should all already be included.

The nice thing about having the records organized this way is you can look at the front of it and get an overview so you kind of have a good big picture of what you're dealing with, and then as you read back further into the notes you can cross reference any testing that was done by looking back to the relevant test section and flipping to the right point in time. The reason for sorting all similar test results together is so that trends over time become more easily apparent.

I suggest that you do not highlight the test results outside the normal range, they are typically already marked in some way by the lab, and some of them may be relevant and some may not (some blood work results really aren't that meaningful if they're a little bit outside the reference range). You won't know which are relevant. I'd just leave that as is.

I'm not an internal medicine doc so maybe other people have other opinions.
posted by treehorn+bunny at 5:54 PM on September 26, 2012 [1 favorite]

If you cannot sort the test results as I outlined (for example, because some labs print a long list of tests all together on the same page, whereas others will do separate pages for separate panels of labs), then just chronological order with the physician notes in front of each round of tests would work. They'll probably already be sorted this way.
posted by treehorn+bunny at 5:56 PM on September 26, 2012

Organize them the way we do in paper charts. No need to organize them by specialty. Everything in each section goes in chronological order, most recent on top.

History and Physical on top. This is the note from your first visit with any doctor. Where they put your vitals and your primary reason for the visit.

All the office notes

Separate all the labs and images (xrays, MRI, cat scan, pet scan) into one section.

Next, all correspondence. Any letter that one doctor wrote to another regarding your care or referring you.

I would not mark up your results. Different docs are going to be looking for different things, and drawing their attention away from what they are looking for may frustrate them. Having things in chronological order lets them see what is recent, so they know what they will want to reorder. It also allows them to search for a trend in your labs.

Marking things outside of the normal range may not be helpful, because normal has to be evaluated in the context of the whole lab panel (a normal high-ish one thing combine with a normal lowish other thing looks normal to non doctors but can scare the crap out of doctors. Or look normal to doctors and scare the crap out of us)

Don't add any extra pages to the pile. Each page should be pure medical information. Doctors spend their days looking at charts, they know how to read the labs and what is significant about the numbers. They don't need a translator.
posted by bilabial at 6:00 PM on September 26, 2012 [2 favorites]

Or what treehorn + bunny said.
posted by bilabial at 6:00 PM on September 26, 2012 [1 favorite]

With animal medicine, a common way to organize a file is the POVMR, or Problem Oriented Veterinary Medical Record, first chronologically, then each "problem" over time, with all findings for each event/problem loosely organized most recent to first.
I wouldnt write on the actual records either, but add a summary or heading page for each problem, if you are so inclined. But the review body is most likely used to organizing these kinds of records to their liking already, so probably you are ok to allow them to do it for you.
posted by bebrave! at 6:03 PM on September 26, 2012

If they get faxed, highlighting can amount to blacking out the info you most want seen. If you write on official records, that can be viewed as "altering" them. You might try sticky notes. Make sure they don't cover anything else.

Consider not using overly huge lettering. When I read medical records for a living, the largest writing on most documents was irrelevant bs like the logo or hospital name, nothing I needed to waste precious time on. Thus screamingly loud, desperate attempts to call attention to something by putting it in size 72 font sometimes backfired and got it completely glossed over.
posted by Michele in California at 6:15 PM on September 26, 2012

I will add that handwritten notes in the margin of otherwise typed records tend to stand out. Or typed notes added to the margin of handwritten records.
posted by Michele in California at 6:22 PM on September 26, 2012

You don't need to add anything to the medical records, but you can put them in a rough chronological order by visit. More than likely, they'll skip to the meat of your records and skim the majority. You'd be surprised how much of a modern medical record is superfluous to a patient's medical course because of billing, legal and documentation requirements.

If your case is being presented in a multi-disciplinary board, one good recent H&P will serve as a sufficient overview for the primary to present, and if there's some ambiguity or question, someone will go in and find the answer in your old records or ask you at your next visit.

One thing that could help tremendously more than the reports is if you could get the actual imaging on CDs and any path slides that you may have. More than the mountain of paper, this serves as a good measure in addition to labs for progression of many diseases, and experience in imaging/path interpretation varies significantly so reports are sometimes insufficient when dealing with complex cases. Most hospitals provide this now, but there may be a small fee ($20-40).
posted by palionex at 6:47 PM on September 26, 2012

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